Obesity Flashcards
Definition of obesity
> 2yo:
Overweight: BMI 85th - <95th %ile for age and sex
Obese: BMI >95th %ile
Extremely obese: >120% of the 95th percentile or >35 kg/m2
<2yo:
Obese: Sex-specific weight for recumbent length is >/=97.7th %ile on the WHO charts
Endocrine causes of obesity
What is an important clinical sign
GH deficiency,
hypothyroidism, or
Cushing syndrome
stature and height velocity are decreased
weight maintained
Comorbidities of Obesity/Overweight
Prediabetes/T2DM
Dyslipidemia
Sleep apnea
Cardiac:
- Prehypertension/hypertension
- Early subclinical atherosclerosis
- Cardiovascular disease (CVD)
GI:
- Esophagus: GERD, Barrett’s esophagus, esophageal cancer
- Gastric: hiatal hernia
- Hepatobiliary: NAFLD, gallstones, pancreatitis
- Colon: diarrhea, constipation, colonic adenomas and colorectal cancer
Renal:
- Proteinuria
- Focal segmental glomerulosclerosis
Hyperandrogenemia/PCOS
Slipped capital femoral epiphysis and pseudotumor cerebri
Depression
Social isolation
Poor quality of life
who should have genetic testing for obesity
- extreme early onset obesity (before 5 years of age)
- clinical features of genetic obesity syndromes (in particular extreme hyperphagia)
- family history of extreme obesity
What are genetic obesity syndrome with developmental delay?
Prader Willi syndrome
AHO
SIM1 deficiency
BDNF/TrkB deficiency
Bardet Biedl syndrome
TUB deficiency
What are genetic obesity syndrome without developmental delay?
Alstrom syndrome
MC4R deficiency (melanocortin 4 receptor)
SH2B1 deficiency
KSR2 deficiency
Leptin deficiency
Leptin receptor deficiency
POMC deficiency
PCSK1 deficiency
Prader willi - inheritance
dominant
genetics of PWS
A methylation disorder caused by the deletion of a critical segment on the paternally inherited chromosome 15q11.2-q12, loss of the entire paternal chromosome 15 with the presence of 2 maternal copies (uniparental maternal disomy), or an imprinting defect that can be sporadic or due to a mutation of the paternally derived imprinting control site of the 15q13 region
genes in monogenic obesity
LEP: Leptin gene mutation
LEPR: Leptin receptor gene mutation
POMC
MC4R
PCSK-1
NTFK2
SIM1
BDNF (BIG DADDY NEEDS FOOD)
hormones or proteins that stimulate appetite
● Agouti-related peptide (AGRP)
● NPY
● Ghrelin
hormones that suppress appetite
● Leptin
● Polypeptide Y (PPY)
● CCK
● GLP-1
● POMC
● PP (pancreatic polypeptide)
● Insulin
types of bariatric surgery
- Roux-en-Y Gastric Bypass - most effective
- Laparoscopic Sleeve Gastrectomy - most common
- Laparoscopic Adjustable Gastric Banding (LAGB) - not used
chronic complications of bariatric surgery
● Dumping syndrome
● Hypoglycemia
● Malnutrition
● Vitamin Deficiencies
● Anemia
● GERD
● Bowel obstruction
● Hernia
features of metabolic syndrome
○ hypercholesterolemia
○ T2DM
○ Brain - Pseudo-tumor cerebri
○ Lungs - OSA
○ Heart - Hypertension
○ Kidney - Microalbuminuria
○ Liver/GI - NAFLD, gallstones, pancreatitis
○ Ovaries - PCOS, Infertility
○ MSK - Joint pain/osteoarthritis and Blount’s
○ Psych - Increased mental health disorders
○ Extremities - Gout & hyperuricemia
what meds are approved for weight loss in children
orlistat
- reducing fat absorption and can decrease BMI
anorexogenic pathway
- effect on appetite
- stimulus wrt food
- neuron
- hormones
suppresses
intake
POMC
leptin, insulin
aMSH
Other:
CCK
Peptide YY
Panc PP
GLP1
orexogenic pathway
- effect on appetite
- stimulus wrt food
- neuron
- hormones
stimulates
fasting
NPY-AgRP
Ghrelin
AgRP, NPY
Factors that Increase Leptin:
○ Increased body weight / weight gain
○ Eating
○ Insulin
○ Glucose
○ Glucocorticoids
○ EtOH
Factors that Decrease Leptin:
○ Fasting
○ Weight loss
○ Beta adrenergic stimulation
○ Androgens
○ GH
○ Smoking
○ Insulin resistance
WHO def of metabolic syndrome
glucose intolerance or insulin resistance and ≥2:
- Elevated TG
- Low HDL-C
- High BMI or waist-hip ratio
- HTN
- Microalbuminuria
Improvements wit bariatric surgery
Reduced:
- BMI
- Type 2 DM
- htn
- dyslipidemia
- CVD risk factors
Criteria for Bariatric surgery
- BMI greater than or equal to 40
- BMI greater than or equal to 35 but less than 40 + at least one of the following comorbidities:
Coronary heart disease
Type II Diabetes mellitus
Hypertension
Diagnosed sleep apnea
Gastroesophageal Reflux Disease (GERD)
other criteria:
- Completion of puberty (tanner IV) (not mentioned in AAP 2022 Guidelines)
- Able to provide informed consent
- Family support with realistic expectations of bariatric surgery
- Regular attendance in a medical obesity program and evidence of positive lifestyle changes
- Mental health stability
C/I to bariatric surgery
- Medically correctable cause of obesity
- Untreated or poorly controlled substance abuse (within the past 12m)
- Concurrent or planned pregnancy (within the next 18mo)
- Current eating disorder
- Inability to adhere to postoperative recommendations and mandatory lifestyle changes
- SickKids says must be Tanner 4
(no age)
Other’s mentioned elsewhere:
- Anesthesia/surgical risk
- Structural GI abnormality
- Developmental Delay
- Smoking within 6 months of surgery
- Recent major cancer (life threatening, within last 2 years)
Short term complications of bariatric surgery
- nausea
- dehydration
- pain
- bleeding
- leak
- infection
- reoperation need
Long term complications of bariatric surgery
NUTRITIONAL (fat sol, anemia, bones)
- ADEK vit def
- iron def
- B12 def
- folate def
- Ca def
- Vit D def
METABOLIC
- hypoglycemia
- metabolic acidosis or alkalosis
- low lytes: Ca, phos, Mg, K, Na
GI
- dumping syndrome
- cholelithiasis
- GERD
- Nausea, bloating, diarrhea
- short bowel syndrome
- abdo operation comp: adhesions, gastrostomy, hernia, obstruction
Sx Dumping syndrome
hypoglycemia
colicy abdo pain
diarrhea
nausea
tachycardia
dizziness
fatigue
diaphoresis
weakness
tremor
drowsiness
palpitations
